I’d like to think this is just one of those chain-of-mistakes sort of things
You know. Someone writes a wrong number on a blue print. Someone else forgets to lock a water-tight door, because someone called them out of the room at just the right moment. Someone else blows off an inspection one day, figuring they’ll get to it the next. Someone changes the mixture on a materials, figuring it’s only used for Purpose A, when in fact someone else has decided it’s usable for Purpose B under th old forumulation. Four, five, six little errors, each innocuous. Next thing you know, a ship blows up and sinks. Once-in-a-blue-moon stuff.
Disasters are like that. Usually it’s not just one massive failure, but several trivial ones. People make mistakes. Policies don’t cover something. Technology fails. Events heterodyne, and … boom.
So I’d like to think that the situation described in the link above (someone who did not have a good flying day) is just a matter of too many people making slight errors in judgment, until the situation escalated into something truly bizarre.
Remember that, next time you make a decision, thinking, “Well, someone else will correct it if it’s wrong.”
Yeesh.
(Link also via Doyce, who seems to get an indavertent enjoyment at dragging me away from actually getting any work done.)